Clinical Documentation Specialist

As a Clinical Documentation Integrity (CDI) Specialist, you will work under indirect supervision, facilitate and obtain appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness, expected risk of mortality, and complexity of care of the patient. In this role you will be you will:

• Educate members of the patient care team regarding documentation guidelines and regulatory requirements, including attending physicians, allied health practitioners, nursing, and case management.
• Support timely, accurate, and complete documentation of clinical information used for measuring and reporting hospital and physician-based outcomes
• Work independently majority of the time with a high degree of autonomy.

In addition to bringing humankindness to the workplace each day, qualified Clinical Documentation candidates will need the following:

Education Requirements

• Nursing Diploma or Associates Degree Required
• BSN preferred

License/Certification Requirements

• Current RN license in state of employment or valid RN license from compact state, required
• CCDS, preferred
• CDIP, preferred

Experience Requirements

• Three years of nursing experience in the inpatient hospital setting (critical care and/or strong med/surg experience preferred) or two years of nursing experience in the inpatient hospital setting and one year of CDI experience
• Must demonstrate Clinical competency through successfully passing Clinical Competency exam through Nuance
• Must demonstrate CDI software competency through passing Clintegrity exam within six months of starting role
• Proficiency with MS Office software
• Proficient in use of Electronic Health Record
• Experience in health information management or hospital quality program preferred
• Self-motivated with excellent interpersonal, critical thinking, analytical, organizational, and writing skills

Physical Requirements

• Sedentary work -(prolonged periods of sitting and exert up to 10lbs force occasionally)

At CommonSpirit Mountain Region, we believe in the healing power of humanity and serving the common good through our dedicated work and shared mission to celebrate humankindness.